Provider Demographics
NPI:1518031558
Name:CHRISTINA L MIDKIFF MD SC
Entity Type:Organization
Organization Name:CHRISTINA L MIDKIFF MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MIDKIFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-288-7408
Mailing Address - Street 1:2023 VADALABENE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5630
Mailing Address - Country:US
Mailing Address - Phone:618-288-7408
Mailing Address - Fax:618-288-7418
Practice Address - Street 1:2023 VADALABENE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5630
Practice Address - Country:US
Practice Address - Phone:618-288-7408
Practice Address - Fax:618-288-7418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036097885174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036097885Medicaid
IL214530OtherMEDICARE GROUP NUMBER
ILDF8821OtherMEDICARE RAILROAD
ILK33873OtherMEDICARE PROVIDER NUMBER
IL036097885Medicaid